Emergency Point-of-Care Ultrasound Detection of Papilledema in the Pediatric Emergency Department.

The application of emergency point-of-care ultrasound has been expanding in pediatric emergency medicine for a decade. In this case series, we describe the detection of papilledema in patients presenting to the pediatric emergency department using this technology and its potential impact on their clinical care.

Ultrasound-guided femoral nerve block for pain control in an infant with a femur fracture due to nonaccidental trauma.

A 3-month-old infant girl was transferred to our emergency department (ED) with a subtrochanteric femoral neck fracture due to nonaccidental trauma. She received multiple doses of parenteral analgesics both before arrival and in our ED. We performed an ultrasound-guided femoral nerve block using 2.0 mL of 0.25% bupivicaine (approximately 1.25 mg/kg) before placing the patient in a Pavlik harness. Successful pain control was achieved within 15 minutes of the procedure allowing pain-free manipulation of the affected extremity. The patient required only a single dose of parenteral narcotics during the ensuing 18 hours. To our knowledge, this is the first report of an ultrasound-guided femoral nerve block used in the ED for pain control in a pediatric patient.

Pediatric syncope: cases from the emergency department.

Pediatric syncope is a common presentation in the emergency department. Most causes are benign, but an evaluation must exclude rare life-threatening disorders. The lack of objective findings can pose a challenge. This case-based review emphasizes the importance of a detailed history and physical examination with electrocardiogram in determining high-risk patients.

Synthesis of 7a-substituted Hajos-Wiechert ketone analogues.

A general and efficient route to 2-substituted 1,3-cyclopentadiones 3 has been developed. This operationally simple, two-step procedure is amenable to multigram scale preparations of these useful synthetic intermediates. These compounds are then transformed to previously unknown, higher analogues of the Hajos-Parrish-Eder-Sauer-Wiechert ketone (enone 1, R = Me) following an enantioselective Robinson annulation.

Total syntheses of the tylophora alkaloids cryptopleurine, (-)-antofine, (-)-tylophorine, and (-)-ficuseptine C.

A concise, efficient and modular approach to the tylophora alkaloids is described, a family of potent cytotoxic agents that are equally effective against drug sensitive and multidrug resistant cancer cell lines. The advantages of the chosen route are illustrated by the total syntheses of the phenanthroquinolizidine cryptopleurine (1) and the phenanthroindolizidines (-)-antofine (2), (-)-tylophorine (3), and their only recently isolated congener (-)-ficuseptine C (4). The key steps consist in a Suzuki cross-coupling between a (commercial) boronic acid and a simple aryl-1,2-dihalide followed by elaboration of the resulting products into the corresponding 2-alkynyl-biphenyl derivatives 27, 33, 41 and 46. The latter undergo PtCl2-catalyzed cycloisomerizations with formation of the functionalized phenanthrenes 28, 34, 42 and 47, which were transformed into the targeted alkaloids by a deprotection/Pictet-Spengler annulation tandem. Due to the flexibility and robust character of this approach, it might enable a systematic exploration of the pharmacological profile of this promising class of bioactive natural products.

Lewis acid catalyzed allylboration: discovery, optimization, and application to the formation of stereogenic quaternary carbon centers.

A full account of the development of the first catalytic manifold for the additions of allylboronates to aldehydes is described. The thermal additions (both diastereospecific and enantioselective) of 2-carboxyester 3,3-disubstituted allylboronates 1 to both aromatic and aliphatic aldehydes give biologically and synthetically important exo-methylene butyrolactones 2 containing a beta-quaternary carbon center. Although the thermal reaction requires 14 d at room temperature to reach completion, the presence of certain metal salts allows for a 12-16 h reaction while preserving the diastereospecificity observed in the uncatalyzed process. Preliminary mechanistic studies on the origin of the catalytic effect are described as well as stereoselective transformations of lactones 2 into cyclic and acyclic stereotriads with potential usefulness as synthetic intermediates.

Recent advances in the activation of boron and silicon reagents for stereocontrolled allylation reactions.

Despite the popularity of boron and silicon allylation reagents in stereocontrolled synthesis, they suffer from a number of inherent limitations that have slowed down their development as synthetic tools for nucleophilic additions to carbonyl compounds and imine derivatives. These limitations are the low reactivity and diastereoselectivity of allyl trialkylsilane reagents, and the lack of catalytic systems for the activation and substoichiometric control of enantioselectivity in the additions of allyl boron reagents. To develop more efficient and general methods for the control of absolute stereochemistry in the resulting homoallylic alcohols, new approaches aimed at solving the problem of activation of allylic boron and silicon reagents are needed. This Minireview describes a number of recent approaches that have been devised to address this problem.

Nonplanar aromatic compounds. 8. Synthesis, crystal structures, and aromaticity investigations of the 1,n-dioxa[n](2,7)pyrenophanes. How does bending affect the cyclic pi-electron delocalization of the pyrene system?

A series of 1,n-dioxa[n](2,7)pyrenophanes (n = 7-12) with increasingly nonplanar pyrene moieties was synthesized by a 9-10 step sequence starting from 5-hydroxyisophthalic acid. The crystal structure of each member of this series was determined crystallographically. Several spectroscopic properties were found to vary with the extent of the nonplanarity of the pyrene unit. The way in which the distortion from planarity of the pyrene system influences its pi-electron delocalization was investigated by using two quantitative descriptors of aromaticity based on geometry (HOMA) and magnetism (magnetic susceptibility and NICS). Both methods suggest that the aromaticity of the pyrene moiety is diminished only slightly upon increasing the bend angle theta from 0 degrees to 109.2 degrees.

Dramatic rate enhancement with preservation of stereospecificity in the first metal-catalyzed additions of allylboronates.

This communication successfully challenges the perception that the additions of allylbonates to aldehydes cannot be catalyzed effectively by added Lewis acids. Using a novel class of isomerically pure, tetrasubstituted 2-alkoxycarbonyl allylboronates (1), we describe that some metals (for example, Sc(OTf)(3) and Cu(OTf)(2)) allow these reagents to add onto aldehydes to yield gamma-lactone products 2 in good yields at temperatures almost 100 degrees C lower than the corresponding uncatalyzed reactions. The large rate enhancement over the uncatalyzed reaction provides a highly improved practical approach to access aldol-like adducts with a stereogenic quaternary carbon center. The crucial role of the 2-alkoxycarbonyl group on allylboronates 1 was demonstrated with control experiments using a model allylboronate lacking such an ester group. Moreover, the stereospecificity observed in the uncatalyzed allylborations is preserved. These observations raise intriguing mechanistic issues such as the suggestion that type I allylmetal behavior is maintained in this unprecedented catalytic reaction manifold.

Novel isomerically pure tetrasubstituted allylboronates: stereocontrolled synthesis of alpha-exomethylene gamma-lactones as aldol-like adducts with a stereogenic quaternary carbon center.

In spite of their inherent isomerization tendency and low reactivity, 1-alkoxycarbonyl vinylcopper(I) intermediates from the conjugate addition of organocuprates onto acetylenic esters were trapped with very high cis-addition selectivity with iodomethylboronic esters in the presence of HMPA. The resulting isomerically pure 3,3-disubstituted allylboronates react with aldehydes in a highly diastereo- and enantioselective manner, providing alpha-exomethylene gamma-lactones with a stereogenic quaternary beta-carbon center.

Lateral ankle sprains and instability problems.

The lateral ankle complex is the most frequently injured single structure in athletes, consisting of 38% to 45% of all injuries. One-sixth of all sports injury loss time is from ankle sprains. In North America, ankle inversion sprains are considered "de rigeur" for basketball participation.

Hypertrophy of pheochromocytoma cells treated with nerve growth factor and activators of adenylate cyclase.

PC12 pheochromocytoma cells treated with nerve growth factor (NGF) in combination with high concentrations of the activators of adenylate cyclase, forskolin or cholera toxin, become more neuron-like in size than cells treated with NGF or with activators of adenylate cyclase alone. Cells treated simultaneously with NGF plus forskolin or cholera toxin paradoxically show less process outgrowth than cells treated with NGF alone. Addition of forskolin or cholera toxin to cells pretreated with NGF, however, produces enlarged cells with intact processes that are indistinguishable from cultured neurons. One possible implication of these findings is that NGF might act in concert with agents that increase intracellular cyclic AMP to cause neuronal maturation during embryogenesis, and that the proper sequence of exposure to these signals is necessary for normal development. Specific activity of acetylcholinesterase is increased by NGF but is unaffected or slightly decreased by forskolin, suggesting that individual aspects of the developing neuronal phenotype are subject to different types of control.

Anti-lymphocyte antibody Leu-7 (HNK-1) recognizes a constituent of neuroendocrine granule matrix.

Anti-lymphocyte monoclonal antibody HNK-1 (Leu-7) reacts with the cell surfaces of natural killer (NK) lymphocytes and with myelin-associated glycoprotein (MAG). This antibody reacts intensely with normal and neoplastic adrenal medullary cells. A small proportion of normal pancreatic islet cells, anterior pituitary, and gastroenteropancreatic endocrine cells also show Leu-7 immunoreactivity. In adrenal medulla, ultrastructural immunocytochemical studies and immunoblot analyses reveal that Leu-7 reacts with an intracellular protein of MW 75 KD which is localized within the matrices of the chromaffin granules. The MW of this protein differs from those of MAG and chromogranin A. The findings suggest that Leu-7 immunoreactivity might be a new marker for specific subsets of secretory granules.

Cooperative regulation of neurotensin content in PC12 pheochromocytoma cell cultures: effects of nerve growth factor, dexamethasone, and activators of adenylate cyclase.

Nerve growth factor, dexamethasone, and forskolin or cholera toxin (CT) act cooperatively to increase the content of neurotensin (NT) in PC12 pheochromocytoma cells. Relatively small increases in NT content occur in the presence of NGF alone or dexamethasone alone, but not of forskolin or CT alone. Increases of 10- to 100-fold occur in the presence of NGF plus dexamethasone or NGF plus forskolin, and up to 600-fold increases occur in the presence of all three agents. These increases are extremely stable and persist for at least 2 weeks after removal of dexamethasone or forskolin. The complex regulation of NT stores in PC12 cells might reflect mechanisms that regulate NT content of normal chromaffin cells and/or neurons during development or in adult life. A small amount of stored NT is released in response to stimulation with 52 mM K+. This release is blocked in the presence of 2 mM Co2+, suggesting that it occurs via Ca2+-mediated exocytosis.